HomeMy WebLinkAboutSeptic Pumping Slip - 178 HAY MEADOW ROAD 3/31/2016 Commonwealth Ith of Massachusetts
City/Town of
Pumping System
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Infrmati®n
1. System Locatio aLift Righ ron:of hous , Left/Right rear of house, Left/right side of house, Left Right side of bu , eft/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
z
Clty/�own ' State Zip Cad
Telephone Number
B. Pumping Record �
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3-90----
o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: r�
6. System Pumpe By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locoon era ere contents were disposed:
G ASign S. Lowell Waste Water
Haule Date
t5form4.doc•06/08 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts �r ,��
u �r irw,'�I2
u
City/Town of
I System Pumping Record
Form 4 ��`k�r�rp�k �l ��iE° AiiDrAEa-I
DEP has provided this form for use by local Boards of Health. Other forms may used,
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio . Lefk/Right-K6-A--o ho.use?Left/Right rear of house, Left/right side of house, Left/
Right side of buil 'try,Left/Right front of building, Left/Right rear of building, Under deck
Address
( C !
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Sta �.°.�y.. Zip Code
'—4
Telephone Number
B. PumpingRecord
1. Date of Pumping 2. Quantity Pumped:
Date Lallans
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p F-1 Yes ❑''No If yes, was it cleaned? El Yes ❑ No
5. Conditi ?n f Sys em:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locat,on.,where contents were disposed:
G.L S. Lowell Waste Water
Sign tu'e Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth lth cif Ma s chin tt
City/Town of
System Pumping Record
Form 4 T(MN OFi,,ICATH AM,14��) P
u)EL R11 s T
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facift Information
1. System Location: Left side of house, Right side of hous , Left front of hous Right front of house,
Left rear of house, Right rear of house. Left rear of building. Rligfif rear o uilding.
--------------
Address tj/ i c
City(rown
---- — -- State -- Zip Code
2. System Owner:
Name----------------
Address(if different from location)
---- --------
-- ---- -----
Cityffown State, ^� ._ .� /1/�7 Co —
Telepphyo+nje Number {
B. Pumping etc rd
— -- 2. Quantity Pumped: —----- -.--.--
1. Date of Pumping Date ty p Gallons
3. Type of system: ❑ Cesspool(s) ®—Septic Tank ❑ Tight Tank
❑ Other(describe): - -- ---------- -- -----------
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson — F5821 _ ----- -------_--
Name Vehicle License Number
Bateson Enterprises Inc -- —
Company
7. Location where contents were disposed:
1:1L S Low l to Water .....
-----
—-- --
Signature of a er Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
-.1-1..,
Commonwealth ®f Massachusetts ������u ��.I1... �.�� .�m.-.
City/Town of w
System Pumping Record 2 1,3, ;,009 u
e"
Form 4 Ta':.b"6 u i OF NOR1 ANDOVER
EA TH DEFIAR i K�i��.,� r
DEP has provided this form for use by local Boards of Health. Other farms may be used u Iie'
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important: .
When filling out 1. System Locatio6�.'''L�``'`e`''ft'front, ft rear, left side of house. RI ht front, right rear, right side of house.
forms the
computer, use ct
only the tab key Address \� ,
to move your
cursor-do not n City[Tow State Zip Code
use the return P
key. 2. System Ow er:
f
--_ Name
Address(if different from location)
City/Town – State Zip Code --—
Telephone Number
B. Pumping Record
1. Date of Pumping ` — 2. Quantity Pumped: C)
Date e Gallons
3. Type of system: Cesspool(s) Septic Tank Tight Tank
p Other(describe): ---
4. Effluent Tee Filter present? [ Yes F2' No If yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/43 System Pumping Record•Page 1 of 1
Commonwealth Massachusetts
City/Town of
System onRecord
Q
,d✓ �(lt✓'r I,.,� f" 1 i i i /I iForm
DFP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the 1 1 ..
computer, use ..�.---- ,
only the tab key Address
to move your °°
'cursor-do not
use the return City/Town �" Stake Zip Code
key. 2. System Owner: ,w...
Name
Address(if different from location)
City/Town State Zip Code,;�(.�4':
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑"'§e' ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑"No If yes, was it cleaned? ❑ Yes E] No
b. Condition of System:
6. System Pu pea By:
Name Vehicle License Number
Company
7. Location here contents w disposed:
0/., c �.
Signat e# auler Date
t5forrn4.doc^06/03 System Pumping Record m Page 1 of 1
Commonwealth of Massachusetts
.g
Massachusetts
NO V
I'
t_
System Owner ,,� _. ... .� System I_,car;atiora��.�_.._...�...��_�,.,. ._._.....�...�...�....,,....�.__._�,....
0.
Date of Pumping: o—I � Quantity Pumped:I 'z�k-" gallons
Cesspool: No [. Yes �_7 Septic"Tank: No (] Yes [.
System Pumped by: License #
Contents transfers°ed to: Greater Lawrence Sanitmia®.d tri
Date: m __ ..._ _Inspector:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING:3 J-5 QUANTITY PUMPED GALLONS
CESSPOOL: NO °DES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY .µ
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: _
(AA
COMMENTS: uv ., _-
CONTENTS TRANSFERRED TO:
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